My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

Why do we seem to need to see the pressure on the NHS as being so overwhelming that we can’t do anything about it?

Filed Under (Alan Milburn, Culture of the NHS, Health Improvement, Healthcare delivery, Reform of the NHS) by Paul on 24-03-2014

One of the main purposes of this blog is to question some of the established orthodoxies of the NHS and how we think about it. By definition that means that I raise questions all the time about how the NHS thinks about the main issues it faces.

For the last five posts during this month of my return to the fray I want to develop a different set of arguments. These will question why so many leaders and commentators in the NHS seem to need to passionately portray the organisation as being mired deep in a many faceted crisis.

There is constant talk about ‘the graph of doom’ which has demography rising and resources flat lining.

I want to explore the nature of the psychological need that is being met by this constant return to viewing the world in this way.

Because, from the outside, all this talk of doom seems to make the job of actually achieving anything very hard indeed.

One way of looking at this is that if there are…

  • too many old people
  • too many sick people (who are also apparently the wrong sort of sick),
  • too many changes in technology
  • sky-high rising public expectations and
  • no new money

…then don’t all of these external factors create a set of drivers which argue relentlessly for the necessity of radical change?

One would think so. But then in the real world where these arguments are being made by and large radical changes of scale are not being made.

So I think we need to think of another purpose that this way of looking at things serves. If all of these external factors are coming together to create pressure for change isn’t it also the case that change on this scale can’t be achieved? So, the argument goes, this is all so overwhelming that nothing can be achieved – so let’s carry on much as we are already.

So the paradox of this week’s posts is that what should be powerful arguments leading to change have in fact become OVERWHELMING arguments resulting in people not knowing where to turn.

I am grateful to my old boss Alan Milburn for showing me how these arguments need to be turned on their head. A few weeks ago at the Guy’s and St Thomas’ Charity he gave a lecture on how all of this overpowering doom could be a set of opportunities for the service potentially leading to very different leadership activities.

Because, as with so many things, this is all about leadership. The framing of the argument is a matter for the leadership of the system. And at the moment that argument is being framed to be so overwhelming that everybody is being frightened back to the status quo.

This week I want to spend a day on each of the five areas which have been portrayed as overwhelming challenges and see what possibilities they provide the NHS.

  • Demography
  • The nature of disease
  • The nature of technology
  • Public expectations
  • The money

On demography I need declare an important interest. I am 65 – the same age as the NHS – and therefore part of the age group and generation that are being seen as the burden that will destroy it.

Personally I don’t quite see myself as a burden but I sort of get the point.

However, my generation – colloquially referred to as the “baby boomers” – has, until now, more often been seen as a generation causing problems because of too much activity – not too much passivity.

We were – just – young mods and rockers (in my case a failed rocker as I never mastered riding a motorbike); we developed and sustained several parts of pop culture; we were the first major wave of student unrest; we were an early part of the property boom; we rode a tide of divorces and changed jobs far more often than previous generations.

All of this seems very active. (For our parents, much too active.)

Apparently now that we are entering retirement we are going – for the first time in our lives – to become a passive burden, rack up several co-morbidities and spend the last 30 years of our lives bothering doctors.

Old people are not just often referred to as a ‘burden’ but we also seem to feature in a lot of ‘drowning analogies’. There is, and will be, a flood of demand which will lead to the NHS drowning under it. All of this becomes a tsunami of need.

One of the statistics used to make this case is that by 2030 a third of the population will be elderly. This is assumed to clinch the whole argument since a problem that big must be insuperable. Personally I would be 82 and be part of this flood by being ill, and passive.

I think it’s certain many of us will be ill. My aches and pains will develop into arthritis and I am pretty sure that my blood pressure will be too high. Almost certainly I will also have another morbidity.

So it’s true that there will be more of us and that many of us will be ill in complex ways.

But will we be ill in the same way as today’s 82 year olds?

When I read the Saturday and Sunday supplements many of them treat me as a very active consumer for the rest of my life. I read them as appeals to me and older generations to become ever more active. There are a whole host of organisations that are looking to me to be very active indeed when I am in my 80s.

Private sector organisations assume I will be very active.

The NHS assumes I will be very passive.

Voluntary sector organisations see me as active.

The NHS sees me as passive.

The NHS assumes that its burden (and the problem of their increasing activity) is caused in part by my passivity.

But what will be the characteristics of my activity that the NHS, if it understood me in that way, could work with?

How might my GP be encouraged to view the next 30 years of my life as a set of assets with which the NHS can work?

One of those assets would be my wish for my home to be the established and clear locus of health care. I do not want care closer to home. I want care at home.

Our care will be centred on our experience of our own homes and not designed for the convenience of the organisations that will deliver it. My generation will expect much more high acuity care in the comfort of our own homes.

This will be a challenge to the current way of working. The new generation of the old will not tolerate a system of care that tells us what to do.  We will want to tell it what to do.

But for the NHS this is also a very considerable opportunity. It will require a shift in the way in which the NHS delivers care but that shift would be based upon a recognition of our capacity to play a much bigger and active role in our own health care.

The opportunity is to re-fashion care so that it is aligned with the mind-set of this century rather than the last.

Mid Staffs: What I might have done better to improve the policy and culture of the NHS. Part 1 (Part 2 next week)

Filed Under (Culture of the NHS, Francis Report) by Paul on 13-02-2013

In the last few days several people who have commented about my blog regarding Mid Staffs have said something to the effect of “What about an apology from you for your part?” and of course, given the depth and the breadth of what happened at Mid Staffs, everybody that had a role in the NHS over those years has to look carefully at what they did and did not do.
Read the rest of this entry »

The Foundation Trust movement at 8 years old

Filed Under (Culture of the NHS, Foundation Trusts) by Paul on 24-10-2012

Today I am at the Convention Centre in Liverpool for the first ever Foundation Trust Network national conference. I’m on the platform on a couple of panels to talk about quality and regulation (of which more later). Read the rest of this entry »

The main role of the National Commissioning Board (NCB)? – maintaining close local control.

Filed Under (Commissioning Board, Culture of the NHS, Reform of the NHS) by Paul on 11-08-2011

This post is the second of the week exploring the role of the NCB. The NCB published its own development plan for consultation in July. It is an organisation of immense power which, if it continues to develop as it plans, will control local NHS commissioning very tightly.

Those who are familiar with NHS culture will not find this surprising. Traditionally it has always looked toward the centre for instruction and the NCB is the latest manifestation of how that central control moves into commissioning. When the power of the NHS ran through its control of secondary care provision – its centre was run through its ownership of all of those hospitals. Read the rest of this entry »

What to do if you want to push on with NHS Reform. Progressive practice in reactionary times.

Filed Under (Culture of the NHS, GP Commissioning, Reform of the NHS) by Paul on 22-06-2011

Given that I don’t know what the Government plans to do about moving forward NHS reform (and, as it seems, neither do they) I thought it might be interesting to write a couple of posts on how a government might continue with reforms – despite the fact that it looks like this one doesn’t..

Interestingly I suspect that this is something that the current Secretary of State for Health may also want to do – even if his Prime Minister no longer wants any more reform. I also think that a sizeable number of NHS staff recognise that an unreformed NHS may not survive the decade and will also want to press ahead with reform – even if the Prime Minister doesn’t. Read the rest of this entry »

Disruptive innovation and the NHS – better outcomes with less resource.

Filed Under (Creating public value, Culture of the NHS, Innovation) by Paul on 09-06-2011

Yesterday I spoke at a conference organised by Reform – the think tank that argues for better and faster reform of the NHS and other public services. It highlighted the ways in which different aspects of the NHS and other health services can make disruptive innovations to improve their outcomes for fewer resources. Of course much of the conference spoke about specific innovations that could both save money and improve outcomes. One of the most inspiring for me was an example from India which I quote at length below. Read the rest of this entry »

Warning! Beware of invitations to come and help the Government.

Filed Under (Culture of the NHS, Narrative of reform, Patient Choice) by Paul on 20-05-2011

Over the last few weeks a few people have been surprised to receive an invitation to breakfast – or a meeting – in an embossed envelope. The embossed mark over the flap looks important and, when they open it, most of them will have been surprised and even a little bit thrilled to find it was an invitation to meet with the Prime Minister to talk about the NHS. Read the rest of this entry »

The NHS and the Tory Party – is it really true love?

Filed Under (Conservative party, Culture of the NHS, Health and Social Care Bill, Reform of the NHS) by Paul on 11-04-2011

This ‘listening exercise’ – even if it is not a serious attempt by the Government to change course – does give the rest of us two months to mobilise both policy and argument for sensible reform after this 11 month disaster. Read the rest of this entry »

The limited effectiveness of top down authority in making modern institutions work.

Filed Under (Culture of the NHS, Health Policy, Reform of the NHS) by Paul on 10-01-2011

One of the interesting cultural experiences of the NHS over the last few months has been the way in which the phrase “Stalinist” has come to be used as a description of actions by people about their own use of their authority. What is most interesting is the fact that the word is not being used in the way in which most of us has become used to hearing it being used over the last 50 years. That is as a term of derision and abuse. “You are just being Stalinist” to describe someone who is being authoritarian and just expects their staff to do what they are told – or else. Read the rest of this entry »

If the answer is David Nicholson – what was the question Andrew Lansley was asking?

Filed Under (Culture of the NHS, Reform of the NHS, Secretary of State) by Paul on 07-01-2011

One of the main issues for Andrew Lansley in 2011, during what is meant to be his first year of implementing his “revolutionary” reforms, is why he has appointed as his main ally in this difficult daily struggle for reform someone who so fundamentally disagrees with him. This disagreement is not intellectual (despite all the attempts at bluster David Nicholson has a very fine intellectual capacity even if he would hate that to be recognised), but is, as we will see, a very significant cultural difference. Culture is “the way in which we do things around here”. And David Nicholson is very much not the way that Andrew Lansley “does things around here”.

How did this happen? Read the rest of this entry »